An investigation into error detection and recovery in UK National Health Service screening programmes

The purpose of this thesis is to gain an understanding of the problems that may impede detection and recovery of NHS laboratory screening errors. This is done by developing an accident analysis technique that isolates and further analyzes error handling activities, and applying it in four case studies; four recent incidents where laboratory errors in NHS screening programmes resulted in multiple misdiagnoses over months or even years. These errors resulted in false yet plausible test results, thus being masked and almost impossible to detect in isolated cases. This technique is based on a theoretical framework that draws upon cognitive science and systems engineering, in order to explore the impact of the plausibility of false test results on the entire process of error recovery. The four analyses are then integrated and compared, in order to produce a set of conclusions and recommendations. The main output of this work is the “Screening Error Recovery Model”; a model which captures and illustrates the different kinds of activities that took place during the organizational incident responses of these four incidents. The model can be used to analyze and design error recovery procedures in complex, inter-organizational settings, such as the NHS, and its Primary/Secondary care structure. Thesis statement This thesis aims to contribute to the safety and overall quality of screening programmes in the NHS, by enhancing our understanding of the problems that may impede detection and recovery of screening errors. Error handling in NHS screening programmes | Nick Chozos, University of Glasgow 1